ENC2010-00133
~ Print Form
Permit No ~ ~ ZG (V - G~ 133
aTY of c/-fltPeEU EHC~ACHMEI±iT ~n
DEPT. OF b+UBLK WORKS (for working within the public X-Ref. File
7Q North First Strwt ri/ght-of-way) Applcation Date
Csrnpball, U 95008 Issued ~_ ~( 2~! ~ p Application Ex}~ration Date 2 /
fx. (408} 376-0958
Permit Expiration Date 9 2~ ~)
APPLIKATION - Applkatbn is hereby made for a Public Works Permit in accordance with Campbell Municipal Code, Section 11.04. (Application expires in six
(6l momhs'rfthe permit is not issued. Applcation Fee isnon-refundable.)
A. Wark Address or Tract No.:
Utility Trench Location:
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8. Nature of Work ~~-V'y"Zd V'~_ / 1-rG.A..CQ~ ~ ~L~ `~ , ~~t„~ '"~ ~V6K-K.P~~ C D /
C. Attach four (4} copies of an engineered plan showing the boatkxt and tent of the work, and four (4} pie of the preliminary Engineer's
Estimate of work. The plans shaft show the relation of the proposed work to existing wrface and underground improvements. When approved
by the City Engineer, said plan becomes a part of this permit
D. All work shall confo-nt to the City of Campbell Standard Speciflcatbns and Details for Public Works Constrtxtbn; the General Permit Conditons
listed on the reverse side; and the Special Provisions for this permit listed bekwv. Failure to abide by these conditions aril provisions may result
En job shutdown and/or forfeiture of Faithful Performance Sureties and cash deposits. {See General Permit Conditions 1 and 2.)
E. The Contractor must have this permit and approved plans at the site and must notify the Publk Works Department at least two days before
starting work. Notice must be given to Public Works at least 24 hours before restarting any work.
Name of Applicant: i ~ ~~ ~ t7-Y1/~
Telephone: ~ ~(} ` f
Address: ~L~' 7 ~ ~~~~ ~~~1~., ~ ,Q
E-Mail Address: ~eCu1 r ~~ (4'-~t!~'r{l/C• n1f'"24-HOUR EMERGENCY PHONE NUMBER:
i th' k bei d the i'
S MOUNT ~ ~.^ RECEIPT NO.~
s rs wor ng one by property owners at their own residence. ~-- y~ ~-- ~
The Appliant/Permittce hereby agrees by affixing their signature to this permit to hold the Clty of Campbell, its officers, agents, and employees free, safe
and harmless hom any claim or demand for damages resulting from the work covered by this permit.
The AppikantlPermittee hereby acknowledges that they have read and understand both the front and bads of this permit and they will inform their
contractors} of the informatbn. Applcant is advised that upon issuance of this permit property owner, or property owner's successors, shall be
responsible for arty and all damages arising ovt of the condition of any private improvements in the publk right-of-way.
Accepted: ~ __ n ~' -'" _ ~
___ L~'~-~__ ~/=~-~/ice _
(Applicant Permittee} (Sign} to
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{Contractor) (Print Name} Dire _ _
SPECIAL PROVISIONS:
t. Street shall not be open cut for underground installations. Minimum cuts may be allowed for connections or exploration holes. Such cuts maybe
soeciflcally aooroved by the In orior to 4uttina.
2. Pavement may be M for underground installations and must be restored in accordance with the Standard Details Trench Restoration Method
"A", unless otherwise approved by the Engireer.
____3. Wor1c to be staked by a licensed Land Surveyor or Civil Engineer and two (2> copies of the cut sheets sent to the Pubik Works Department
before startktg work
4. Per Section 4215 of the Government Code this permit is not valid for excavations until Underground Service Alert {USA) has been notified and
the inquiry Identification number has been entered hereon. USA Phone: 1-800-227-2600. USA TICKET NO.
5. Prior to any work, the property owner shah execute an Agreement for Private Improvements in the Publk Right-of-Way, which shall be
recorded.
6. Publk NotlRcat~n Requirements:
7.
SEE PUBLIC WORKS FEE SCHEDULE FOR CURRENT FEES
PERMIT APPLICATION FEE
PLAN CHECK DEPOSR
SECURITY FOR FAITHFUL PERFORAAANCE/LABOR & MATERIALS
COL~STRUCTION CASH DEPOSIT
PLAN CHECK & INSPECTION FEE
APPROVED FOR ISSUANCE
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Permit
$~
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For Chy Engineer
12 Months After Date of Issuance
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i. A Construction Cash Deposit is required. Charges will be made against this deposh if there is an emergency call-out overtime inspection or when City
ordered barricading is required. Any such costs in excess of the deposit will be billed to the Permittee.
2. A one-year maintenance period and wrety are required. Such period will begin on date of written acceptance by the City.
3. Refund or the cash deposit balance and refund or cancellation of the Faithful Performance Surety will be initiated by the written acceptance of the work
bythe City.
4. The Permittee must request in writing a firwl inspection and acceptance of the work upon tompktion. Acceptarxe by the City wfN be made in writing
to the Permittee.
5. Mairnafn safe pedestrian and vehicular crossings and free access to private driveways, bus stops, fire hydrants, and water valves.
6. A Constructkxt Troffk Carnroi Plan and a Construction Schedule are required for all lane closures, detours, and street cbsures. This plan must be
reviewed and approved prior to any lane closures.
7. A Construction Traffic Control Pian shall conform to the Caltrans Manual ofTraffic Controk for Construction and Maintenance Wwk Zones, dated
1990, available at Caltrans. Traffic cornro! equipment shall include Type II flashing arrow signs if required.
8. Replace as directed by the City Engineer any damaged or -emove6 improvements in accordance with City Standards and Specifications at the sole
expense of the Permittee.
9. Sawcut for all PCC or AC removals. All PCC removals shall be to the nearest scoremark and shall be doweled to existing improvements.
10. Prior approval of inspector is required for any work done after normal working hours, on weekends or hdidays and may require reimbursement of
inspection costs at ttte current overtln-e rate.
11. Adequate signing and barricading is required on the job s}te. Failure to provide such signing and barricading may result in the City's providing signing
and barricades and charging the cost (irxluding all labor and materials) against the cash deposit.
12. Compaabn testing of subgrade, base rock, and asphalt concrete by Permittee Is required unless otfierwise stated by the Ciry Engineer.
13. The Contractor or Permittee will have a wpervisory representative available for contact on the project at ail times during construction. Contractor or
Permittee shah provide a phone number at which they can be contacted outside the hours of 8:00 a.m. to 4O0 pm.
14. No storage of materials or equipmern will be allowed near the edge of pavement the traveled way, or within the shoulderline which would create a
hazardous condition to the public.
15. This penrdt shall not be construed as authorization for excavstkm and grading on private property adjacent to the workor any other work for which a
separate permit may be required, nor does it relieve the Permittee Of any obligatbn to obtain arty other pe-rMt required bylaw.
16. This permit does not release the Permittee from any liabilities contained in other agreements or comracts with the City and any other publk agency.
17. Tt>is perrt~t is not transferable. Work must be performed by the Permittee or his designated agent or contractor as speared thereon.
18. Cali back (call out) due to eme-egencies regarding this permit shall be at the current overtime rate with a three (3) hour minimum charge per
occurrence.
19. Pursuant to Chapter 14A2 of the Campbell Murtidpal Code, applicant shall not cause to be discharged any material into the municipal storm drain
system other than storm water. Appikant shall adhere to the BEST MANAGEMENT PRACTKES established by the Santa Clara Valley Urban Runoff
Pdlution Prevention Program.
20. flthe publk interest requires a modifkation of, a a departure from the plans and specifications, the City shall have the authority to require or approve
any modificatbn or departure and to specify the manner in whkh the same b to be made for City-owned or maintained facilities.
21. Permitttee must provide advance notification to all parties that may be affected by the permit activities. Notircation shall fx reviewed by the City prior
to distribution and include dates of work and a contact name and phone number.
Applicant shall be responsible for ensuring that all those providing services underthe applicarn are aware and understand all of the above conditions.
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Applicary / Gate:
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Contracts (Print Name) Oate:
J:IFORMS\TemplateslEncroachment Permits\ErKroachment Permit STATK form2.pdf
Rev. 3/08
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